Q. Why did you become a
psychiatrist?
Initially my desire was to be a general
practitioner. In medical school I thought I
wanted to pursue Internal Medicine and
sub-specialize in cardiology. During my
internship I began to realize that this was not
really what I wanted, so I joined the U.S. Navy
during the Viet Nam Conflict and spent two years
assigned to the Marines as a General Medical
Officer. Only when I was just about to get out
of the service did I finally realize -or admit
to myself- that I just did not want to return to
an Internal Medicine residency. So I decided to
"try a year of psychiatry residency" to see how
I liked it. And I suppose I must have liked it -
for here I am, thirty years later, still
practicing psychiatry!
Q. What was it
about psychiatry that interested you enough to
"try a year" of residency in it?
Like most medical students and interns of my
day, I had regarded psychiatry and psychiatrists
as the lowest of the low in terms of medical
specialties. We laughed at and made fun of the
whole field, looked down on those who tried,
usually without success, to teach us something
about it, and viewed the subject of emotions and
medical practice as unscientific and absurd.
Psychiatrists, we thought, were weirdos
themselves, doctors who for some reason couldn't
live up to the strenuous requirements of the
medical calling and who therefore bailed out and
became the equivalent of glorified social
workers. Psychiatric reisdents were called
"spooks." We wanted to deal with hard data, lab
tests, physical findings, X-rays and other
topics with which we felt comfortable.
Underneath all of this contempt and criticism of
psychiatry, of course, there was a great deal of
fear that there might really be something to it
after all, and that we ourselves might not be as
well-adjusted or sane as we liked to tell
ourselves.
My actual interest in psychiatry crystallized
during my last six months on active duty when I
was a general medical officer at a Marine Corps
dispensary on Okinawa. Many of our patients had
personal problems and concerns that they had no
place else to talk about. And I was quite
surprised to discover for myself, almost by
accident and basically because I was bored and
had nothing else to do, that just listening to
people could help them to become better. I had
of course been told that before. But I didn't
believe it until I saw it myself. The positive
benefits of simple sympathetic listening came as
a kind of revelation to me.
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Q. It sounds like
your original desire to be a general
practitioner underwent some drastic changes.
Considering how I made my original career
choice, it could hardly have been otherwise. For
my determination to become a physician began
when I was eleven or twelve years old. It was
derived chiefly from seeing some TV re-runs of
"Dr. Kildare" movies, the original ones,
starring Lionel Barrymore as Dr. Gillespie and
Lew Ayres or Van Johnson as young Doctor
Kildare. Nobody in my family was a physician. I
had no idea what I was getting into. It wasn't
like it was in the movies. As soon as I got to
Emory medical school I realized that becoming a
specialist, not a general practitioner, was the
dignified thing to do. So I set my sights on
cardiology because the chairman of the internal
medicine department was a famous and respected
cardiologist. But when I was a medical intern on
cardiology rounds, I never could seem to
remember to bring my stethoscope and always had
to borrow one to listen to heart sounds. That
should have told me something then, but it did
not. I recall being surprised and having my
feelings hurt when, after three or four such
incidents of "forgetting" to bring my
stethoscope on rounds, the attending physician
told me that I wouldn't be able to come on
rounds in the future unless I remembered to
bring my stethoscope! I thought he was being
unreasonable! But the truth, as my forgetfulness
showed to everyone but me, is that I was not
very interested in cardiology. On top of that, I
wasn't very good at it.
Q. If you had to
do it all over again. . .?
What a frightening thought! I'm not sure I
could. I definitely would not try. I don't like
the direction psychiatry has taken and the
superficial way it tends to be practiced today,
even though I have personally been able to avoid
participating in such schemes as so-called
"managed care" with their third party
intrusiveness and routine boundary violations. I
suppose if I were given a second shot I would
aim for something like a college professor,
perhaps in medieval history or philosophy,
in an obscure institution somewhere off the
beaten track.. Then again, I might become an
attorney. Of course that would bring its own set
of problems. The grass is always greener.
All in all, I'm happy matters have turned out as
they have. I can't think of anything I'd really
rather be doing at this stage of my life and
career.
Q. What interests
you today about the practice of psychiatry?
Pretty much the same thing that interested me
in the beginning: How, under the right
circumstances, people are able to change and
grow. Since I began my training in 1971,
psychiatry has become far more concerned with
medications and brain chemistry than it was
then. There have been some amazing advances in
this regard - and more are on the way. But what
really interests me is the human or
psychological dimension - the so-called "talking
cure." A great deal has changed in the way
psychiatry is practiced since I began my
career, not all of it for the better, and most
of it, I suspect, driven by economic forces.
Many private practice psychiatrists today do
little more than prescribe medications, leaving
such psychotherapy as the patient may obtain to
non-medical counselors. Some patients get
nothing but the pills, usually in the form of
extremely brief "medication check" visits
of 15 minutes or less. An enterprising
psychiatrist can easily see 20, 30, or 40 or
more patients a day under this system, which is
essentially the same one used in public mental
health facilities for indigent patients.
Q. So it's
better to get to the bottom of things than it is
to take medications?
That's not quite what I said! I said that what
really interests me is the human or
psychological dimension - not
that I don't think medications are helpful. It's
not a matter of Either-Or but of Both-And. Many
conditions benefit from appropriate medications,
although of course many do not require
medication. It's a very individual thing. When
medications are needed and used correctly, they
actually assist the individual in understanding
and working through whatever problems they may
have. That said, there is no getting around the
fact that contemporary psychiatry has become
overly medication-reliant at the expense of
psychotherapy. I understand that in recent years
some psychiatry residency programs have even
stopped training residents in psychotherapy,
concentrating instead on psychopharmacology and
brain chemistry. Medications are valuable and
sometimes necessary; they are seldom if ever the
whole solution.
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Q. But don't
tranquilizers just cover up a person's real
problems?
Not if they are prescribed properly and taken
correctly! Of course if a person is given
or takes too much of a medication, or takes it
for the wrong reason, there can be negative
results - including making it harder for them to
know what is going on in themselves. But the
other side of the coin is the person who is
simply too anxious or depressed to be able to
think straight for very long. In situations like
that, relieving the anxiety and depression with
the right medicines can actually help the person
to identify and deal with what is bothering
them. In these circumstances medication is the
first step in the larger process of
understanding and changing themselves and their
environment.
Q. What are the
most common problems you see in your practice?
I suppose they could all be put under the
general heading of "unhappiness," though the
reasons for that unhappiness vary considerably.
Some form of depression is undoubtedly the most
common condition most private psychiatrists
encounter. Naturally this will vary according to
the type of practice and the kinds of patients
one deals with. But depression, whether
biochemical in origin, psychological, or as
often happens, both, is the commonest finding.
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Q. What causes
depression?
Lots of things, and sometimes several things at
the same time. Depression is a very confusing
word and can mean different things at different
times. It refers both to a primary condition and
to a symptom - as well as to a mood or state of
mind that may or may not be abnormal. On top of
that, it is perfectly possible to be depressed
and not even know it. There have been many
classifications of depression in an attempt to
end the confusion. But for the average person,
this has only added to the problem. Taken alone
and in isolation, the word depression has
practically no useful meaning in psychiatry. It
must be located and understood within the
broader context of a specific individual to be
meaningful.
Q. What is a nervous
breakdown?
Another term that means whatever the person
using it chooses it to mean. Nervous
breakdown is even less useful than depression,
since there is no agreed upon definition
whatever of the phrase. It is not a category or
concept used by psychiatrists at all. In common
speech it refers to a severe emotional crisis of
some kind - usually one in which the individual
feels overwhelmed and that he has taken all he
can take and can't take any more. It may or may
not be associated with a temporary loss or
impairment of function. It's interesting that so
many people seem to believe that it actually
means something more definite than this - so
much so that they may at times fear undergoing
this quite harmless and imaginary phantom, the
dreaded nervous breakdown. Probably
the most common thing that is meant when this
term is used by laypersons is moderate to severe
clinical depression. But it literally means
whatever the person using it chooses it to mean.
It is not useful.
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Q. Do you consider
yourself a Freudian?
No -or rather if so, only in the sense that
today everyone in our culture is a Freudian -
whether they realize it or not. Freud's way of
thinking and many of his insights have become an
essential part of who we are today. It is
literally unthinkable to suppose that we could
do without Freud. Freud was a pioneer who was
mistaken about many things, sometimes in a
particularly embarrassing manner when viewed
from our modern perspective. But what he got
right, he got spectacularly right. He was a
modern Archimedes who found a place to stand
from which he moved our world. But it has been a
long time since most psychiatrists took his
doctrines of libido(the sexual etiology of all
neuroses) or the Oedipus Complex seriously as
universal explanations.
Q. Is it true that
psychiatrists have their own share of
emotional difficulties?
Not just psychiatrists, but absolutely
everybody has their share of emotional
difficulties! Nobody gets through life unscathed
- despite how it might look from a distance or
from the outside. There simply are no normal
people - if normal means to be free of personal
problems, stress and conflict. It is normal to
have emotional conflicts, stress, and occasional
life crises. And although every individual is to
some degree different, I think it is probably
safe to say that, in general, people attracted
to the mental health professions as a career
probably have experienced more distress than
average in this regard. This is probably a
result of being more sensitive to begin with, as
well as, in many cases, some difficult times in
childhood. I certainly fit this description.
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Q. Are there any
books you'd recommend for people interested in
psychiatry?
Almost all of the popular self-help titles have
something of value in them. We've tried to list
some of our favorites at appropriate places
elsewhere in the web site. Many of the links to
outside sites also contain suggested reading
material on various mental health topics. People
seem to vary tremendously in their ability to
benefit from reading such books, with some
people swearing that such reading has changed
their lives, and others, the majority, either
not reading them at all, or not noticing much
benefit from doing so. If I had to pick one book
to read for general self-understanding and
personal growth, it would be Neurosis and Human Growth: The
Struggle Toward Self-Realization, by Karen
Horney M.D. This work deals with some basic,
probably universal human Dilemnas that everybody
faces - regardless of specific diagnosis.
Another approach involves the study -reading is
perhaps too casual a term- of classic works such
as the Meditations of the Emperor Marcus
Aurelius and the Discourses of Epictetus. The
Nicomachean Ethics by Aristotle contains the
secret of happiness for those willing to look
for it and practice it. The biographical works
of Plutarch, the Essays of Montaigne, and those
of Emerson have much of value to commend them to
anyone in search of wisdom about life and human
beings. And from the East there are, among
others, the Analects of Confucius and the
Upanishads. A familiarity with history, that is,
with how human beings have behaved in the past,
lends perspective and forms the basis of wisdom
in human affairs.
But in general, I have not been too much
impressed with the beneficial results of reading
alone in these matters. Sometimes reading itself
is an attempt to avoid or escape from difficult
relationship issues - or to try to get by
without letting others in on one's problems.
Reading seems to work best when there is someone
around to discuss things with.
Q. And finally, do
you have any words of wisdom to impart after
three decades of clinical work?
The fundamental human problem seems to be that
of wanting, sometimes in fact demanding to have
one's cake and eat it too. That is, we seem
almost hopelessly inclined as a species to
desire to have things and circumstances that are
either inherently contradictory(for example,
complete freedom and complete security at the
same time) or are, for some more particular
reason, impossible to obtain(as in the case of a
relationship which has many good qualities but
is not 100% to our liking 100% of the time).
Learning to recognize and deal with the fact
that having one's cake and eating it too is not
possible is probably the main task we all face
in coming to a healthier and happier adjustment
to life. In Freudian language this represents
the accomodation of the Pleasure Principle to
the Reality Principle; in ordinary language it
is called 'growing up.'
See also Dr.
Garrett's Weblog: The
Psychiatrist
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